Library Card Registration Form

Updated: March 31, 2005

Register for a library card online! Simply complete the information on this form. A library card will be prepared for you to pick up at the library you check below. You will be notified by phone or e-mail when it is ready. Do not use this form if you are reporting changes to an existing library card or if you already have a card at an area library. Please allow 10 days for the card to be processed.

When you pick up your card you will be required to sign the application form and present proper identification (a driver's license, a state-issued identification card, or some other form of photo identification showing your current name and address.) Children or young adults under the age of 18 will be required to have a parent or legal guardian sign the application form and present identification.

I wish to register for a library card at:	Kimberly Little Chute
I prefer my library card to be:	credit card size key card size
Last name:
First name:
Middle initial:
Resident of (choose one and specify):	Town of Village of City of
County of residence:
Current address:	Street:
	City:
	State: Zip code:
Home telephone:	xxx-xxx-xxxx
Work telephone (if applicable):
Email address (optional):
Email Notices:	Check to receive reserve and overdue notices by email
Date of birth:	(M/D/YYYY)
I am:	male female
If above address is seasonal, list out-of-town address:	Street:
	City:
	State: Zip code:
Dates at out-of-town address:
If under the age of 18, the name of a parent or LEGAL guardian who accepts responsibility for library items:
If a student, school attending:
You will be notified by phone or e-mail when your library card is ready to be picked up. At that time you will be required to sign the application form which states: "I accept responsibility for library materials borrowed with the library card issued to me until I report the card lost or stolen. I agree to pay fines for materials returned to the library after their due date and to reimburse the library for materials that are lost, damaged or stolen."

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